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Procedures Intermediate Format Enucleation/Evisceration/Exenteration.

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Presentation on theme: "Procedures Intermediate Format Enucleation/Evisceration/Exenteration."— Presentation transcript:

1 Procedures Intermediate Format Enucleation/Evisceration/Exenteration

2 Objectives Assess the related terminology and pathophysiology of the eye. Analyze the diagnostic interventions for a patient undergoing an enucleation. Plan the intraoperative course for a patient undergoing_____________. Assemble supplies, equipment, and instrumentation needed for the procedure.

3 Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for enucleation. Describe the care of the specimen

4 Terms and Definitions Globe Enucleation vs Exenteration vs Evisceration

5 Definition/Purpose of Procedure Removal of the globe of the eye Reasons –Intraocular malignant neoplasm –Penetrating ocular wound –Painful blind eye –Extensive damage/disfigurement

6 Pathophysiology

7 Surgical Intervention: Special Considerations Patient Factors –Pediatric measures: prevention of hypothermia, communication techniques, distraction Room Set-up Anesthesia –General anesthesia preferred over local –Retrobulbar injection

8 Surgical Intervention: Positioning Position during procedure –Supine Supplies and equipment –Head donut headrest Special considerations: high risk areas Prep: betadine paint from hairline to mouth and from nose to ear on operative side (avoid in eyes or ears) Irrigate globe w/NS using bulb syring, from inner to outer canthus; one gtt of ½ strength povidone-iodine solution may be instilled into eye before irrigation

9 Surgical Intervention: Special Considerations/Incision Special considerations State/Describe incision

10 Surgical Intervention: Supplies General Specific –Suture –Medications on field BSS to moisten eye/irrigate anterior chamber— STSR may be responsible to irrigate cornea w/BSS q seconds to prevent drying of tissues –Catheters & Drains –Retrobulbar Block: 5 mL syringe & 1/1/2 inch needle

11 Surgical Intervention: Instruments General (Basic): eye speculum &/or lid retractors, muscle hooks, knife handles (#3 and micro- beaver), scissors (Stevens tenotomy, Wescott), forceps (fine and heavy Bishop-Harmon), calipers, needleholders (micro and heavy), irrigating cannula (for BSS use bulb tipped; for instilling intraocular meds/air use 27 g angled blunt) Specific: see eye extras; conformers & spheres-- prosthetics

12 Instruments for surgery of globe or orbit

13 Some other instruments, conformers

14 Surgical Intervention: Equipment General Specific –Operative microscope –Bipolar ESU

15 Surgical Intervention: Procedure Steps Overview Traction sutures are placed in upper and lower eyelids Conjunctiva is incised Eye muscles are severed Recti and inferior oblique muscles are anastomosed Optic nerve is severed Globe is removed Sphere is introduced into the socket Conjunctiva and Tenon’s capsule are sutured over the sphere

16 Surgical Intervention: Procedure Steps Surgeon places suture (4-0 silk on fine cutter) thru upper eyelid and tags it with fine hemostat. Same step at lower eyelid –The above sutures retract the levator muscles away from the area o of dissection & prevent their injury Surgeon makes a 350 degree incision around the cornea in the conjuntiva as close to the limbus as possible. Incision is made w/ # 15 Bard-Parker blade or delicate iris scissors. –This saves as much conjunctiva as possible for closure later on Using the iris scissors, the surgeon undermines the conjunctiva and Tenon’s capsule and prepares to sever the recti and oblique muscles from the globe

17 Fuller p. 591: A. A 350-degree incision is made as close to the limbus as possible. B. Implant sphere is sutured in place

18 Surgical Intervention: Procedure Steps Because the recti muscles will be sutured to the inferior oblique muscle, both muscles are tagged with suture of silk or Dexon, size 4-0 or 5-0. The superior oblique muscle is severed and allowed to retract back. The surgeon then severs the previously tagged inferior oblique muscle, secures it to the lateral rectus muscle with 4-0 silk suture, and pulls the globe anteriorly (forward). –STSR will have a muscle hook available now. Surgeon passes the hook around the globe to ensure that all connections except the optic nerve have been severed. Surgeon places a Mayo clamp across the optic nerve seconds to effect hemostasis

19 Surgical Intervention: Procedure Steps Surgeon removes the clamp and uses curved enucleation scissors to sever the optic nerve across the area crushed by the Mayo clamp. This frees the globe, which is passed to the STSR for specimen. If any intraocular contents have extruded into the socket, they must be cleaned out with irrigant and 4x4 gauze sponges. Once the globe is removed, an implant must be placed and sutured to the socket to give it shape. –STSR will have several sizes of implant spheres –usual adult range is mm. Surgeon selects the implant and conformer, and the sphere is introduced into the orbit

20 Surgical Intervention: Procedure Steps –STSR passes 4-) Dexon to surgeon, with scleral biting forceps. Tenon’s capsule is pulled the sphere and sutured in place. Surgeon sutures the recti muscles to their appropriate positions on the sphere with 4-0 or 5-0 Dexon. The conjunctiva is closed with 5-0 Dexon. –STSR passes conformer to surgeon Silk retraction sutures are removed. Surgeon instills antibiotic ointment. Dressing of cotton eye pad is secured with tape. In 4-6 weeks, a prosthesis may be fitted (not a surgical procedure).

21 Fuller p. 591: C. Tenon’s capsule is closed over the sphere.

22 Counts Initial—sponges and sharps First closing Final closing –Sponges –Sharps

23 Specimen & Care Identified as eyeball rt vs lt Handled: routine, etc.

24 Postoperative Care Pressure Patch Pain Eye drops and oral meds

25 Complications

26 Ocular Prosthesis

27 Resources STST pp Alexander’s pp. 687 – 689 Complete Review for Surgical Technology by Boegli, Rogers, McGuinness Lemone & Burke p

28 Which term refers to complete removal of the eye? a.Vitrectomy b.Lensectomy c.Enucleation d.Evisceration

29 The procedure involving removal of all orbital contents is called: a.Enucleation b.Evisceration c.Vitrectomy d.Exenteration

30 The space between the lens and the iris/pupil is called the: a.Anterior cavity b.Posterior cavity c.Anterior chamber d.Posterior chamber

31 A trephine is an instrument used to a.Make a circular cut b.Remove a cataract c.Scrape diseased tissue d.Coagulate tissue

32 An opacity of the crystalline lens is referred to as a/an a.Petergyium b.Strabismus c.Chalazion d.Cataract

33 The Trigeminal nerve is also known as the a.Optic nerve b.Fifth cranial nerve c.Oculomotor nerve d.Third cranial nerve

34 BSS is used intraoperatively to a.Constrict the pupil b.Replace vitreous humor c.Irrigate the cornea d.Prevent infection

35 Why is hydroxyapatite used following enucleation? a.Provide a stent during reconstruction of the lacrimal system b.Provide a base of support for the artificial eye c.Replace the cornea d.Replace the crystalline lens

36 The operative microscope in opthalmic surgery often uses which objective lens distance? a.100 b.175 c.250 d.400

37 Drapes included in the eye pack are 1. Split sheet 2. Plastic eye sheet 3. Head drape. The order in which they will be used is: a.1, 2, 3 b.2, 3, 1 c.3, 1, 2 d.3, 2, 1

38 Preoperative drops administered were recorded as “Clyclogel gtts ii O.S. q 5 min times 3.” This means: a.11 drops of medicine were put in the patient’s left eye five times, 3 mintues apart b.2 mL were put in the right eye five times at 3-minutes intervals c.2 drops were placed in both eyes three times at 5- minute intervals d.2 drops were placed in the left eye three times at 5- minute intervals

39 The medication which may be added to a local anesthetic to increase absorption and dispersion/spreading is: a.Sodium hyaluronate (Healon) b.Hyaluronidase (Wydase) c.Alpha-chymotrypsin (Chymar) d.Epinephrine (Adrenalin)

40 Which drug/solution would be used to constrict the pupil immediately following removal of a cataract? a.Acetylcholine (Miochol) b.Methylprednisolone (Depo-Medrol) c.Tropicamide (Mydriacyl) d.Tetracaine Hydrochloridae (Pontocaine) 0.5 %

41 The classification of medications used to dilate the pupil while inhibiting the ability to focus are: a.Mydriatics b.Cycloplegics c.Hyperosmotic agents d.Miotics

42 Miotic agents include all of the following EXCEPT: a.Phenylephrine b.Acetylcholine c.Miostat d.Pilocarpine

43 Injectable agents for opthamologic anesthesia include all of the following EXCEPT: a.Xylocaine b.Wydase c.Tetracaine HCL d.Sodium hyaluronidase

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